Hand and Wrist BOA Instructional Course Manchester 2019 Prof David - PowerPoint PPT Presentation

Hand and Wrist BOA Instructional Course Manchester 2019 Prof David Warwick MD FRCS FRCS(Orth) European Diploma of Hand Surgery www.handsurgery.co.uk

 Dupuytren’s Disease  Flexor Tendon Repair  Wrist Arthritis  Distal Radius Fractures  Scapholunate reconstruction

 Dupuytren’s Disease  Flexor Tendon Repair  Wrist Arthritis  Distal Radius Fractures  Scapholunate reconstruction

Heterogeneity of disease Stumps Twigs Logs 2018

Different bikes for different terrains

Heterogeneity of disease  Some cords are more suitable for surgery  diathesis  dense cords  skin involvement  Some are more suitable for PNF or Xiapex  thin MCP cord

We should be thinking of offering more needles Much quicker Much more Much cheaper recurrence Much safer Much quicker return to work

Developments in surgical technique Invasive surgical procedures • Open-heart surgery • Hysterectomy • Angioplasty • Cholecystectomy Minimally Invasive Procedures • Appendicectomy All common until 1990s • EVAR • Laparoscopy/Keyhole • Lithotripsy Mainly used after 2000 8

Percutaneous needle fasciotomy recurrence and complications Study Badois (1993) Foucher (2001) Van Rijssen (2006) Patients 123 hands 100 rays 55 rays Recurrence 50% (5 yrs) 58% (3.2yrs) 65% (33 months) Complications – Nerve injury (0.05% - 2%) – Skin fissure (16 - 46%) – Flexor tendon rupture (0.05%) – Arterial injury – Infection (2%)

Xiapex recurrence 100 90 80 65.7 70 62.2 56.4 60 2 years 46.7 50 3 years 42.4 39.5 35.2 40 33.7 34.8 4 years 27.1 30 5 years 19.6 20 14.2 10 0 Overall (n=623) MP Joints (n=451) PIP Joints (n=172) Peimer C, Blazar P, Coleman S, Kaplan T, Smith T, Lindau T. Dupuytren Contracture Recurrence Following Treatment With Collagenase Clostridium Histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-Year Data . J Hand Surg (Am ) 2015;40:1597-1605

Return to work  PNF 2-7 days  • Tonkin MA, Burke FD, Varian JPW (1984) Dupuytren's Contracture: A  CCH Comparative Study of Fasciectomy and Dermofasciectomy in One Hundred Patients . Journal of Hand Surgery 9: 156 4-10 days •  D. Warwick, et al Collagenase Clostridium histolyticum in patients with Dupuytren’s contracture: results from  Fasciectomy POINT X, an open-label study of clinical and patient-reported outcomes J Hand Surg 2015; ;40E: 124-32. • 4-8 weeks van Rijssen AL et a J Hand Surg  2006;31A:717 – 725A Comparison of the Direct Outcomes of Percutaneous  Skin graft Needle Fasciotomy and Limited Fasciectomy for Dupuytren’s Disease: A 6-Week Follow-Up Study 6-8 weeks 

UK data

CCH (Xiapex) “a surgical drug” Theoretically dissolves a segment of cord • Therefore more effective • Therefore less recurrence PNF CCH But is this concept true?

• N=140 • PIP only • N=50 • RCT • RCT 3 year follow • Initial Correction • No difference at 1 year • N=96 • Recurrence • PNF 100% • Hand function • Recurrence • CCH 89% • 43% PNF • Recurrence • 34% CCH • PNF 68% • Function • CCH 83% • Unchanged • URAM • DASH

 PNF works as well as Xiapex  PNF is preferable to CCH  Quicker (no second manipulation)  Safer (no chemical side effects)  Cheaper (drug costs 1000 Euros)

 Dupuytren’s Disease  Flexor Tendon Repair  Wrist Arthritis  Distal Radius Fractures  Scapholunate reconstruction

2018 • Key points • 4 or 6 strand suture • Sparse peripheral sutures • Allow repair to be bulky not gappy • Aggressive pulley release • Less wrist restriction in splint • Early active motion

6 or 4 strand 3-0 or 4-0 Not fibre wire

Functionally relevant bowstringing does not occur if A4 or A2 released Better bowstringing than triggering

The Manchester short splint: A change to splinting practice in the rehabilitation of zone II flexor tendon repairs Peck, Rowe, Duff, Ng, Hand Therapy 2014 19 47-53 • Allows wrist flexion and extension • Tenodesis • Early active movement

 Dupuytren’s Disease  Flexor tendon repair  Wrist Arthritis  Distal Radius Fractures  Scapholunate

Wrist Arthritis o Wrist replacement is “work in progress” o Don’t forget neurectomy o Use preserved cartilage

Wrist Arthritis o Wrist replacement is “work in progress” o Don’t forget neurectomy o Use preserved cartilage

59% complication 39% revision Follow Up 35 +/- 28 months

 Yeoh D, Tourret L (2015) Total wrist arthroplasty: A systematic review of the evidence from the last five years . J Hand Surg Eur ; 40:458-468 8 articles 405 implants, 7 types FU 2.3 to 7 years Motec best DASH Maestro best ROM Universal 2 highest survival Biax 69% complication Remotion lowest complication The evidence does not support the widespread use of arthroplasty over arthrodesis

❓ What journal would publish a THR or TKR paper with such short term results Unless they are bad results ❓ Which surgeon would use implants with such a complication and revision rate And o No NJR o No Beyond Compliance

Motec (Gibbon) • Uncemented ball and socket  Complications • 110 wrists  33% total • 63 cases > 5 years follow up  9% Revision for loosening • 82% projected survivorship at 10  4% fusion for infection/malposition years • ROM 125 degrees total flexion extension radial tilt ulnar • tilt • PRWE 25

Wrist Arthritis o Wrist replacement is “work in progress” o Don’t forget neurectomy o Use preserved cartilage

Wrist Denervation • Hilton1862 • The nerve crossing a joint innervates that joint • Wilhelm 1959 • Wrist joint denervation • 5 incisions • Berger 1998 • Single incision AIN and PIN

JHS (2018) 43:272-77 • No evidence that proprioception is damaged • No need for pre-op injections • Results • Satisfaction 70-90% • Good/excellent 70-90% • Survival 68-85% @ 2.6 years

Wrist Arthritis o Wrist replacement is “work in progress” o Don’t forget neurectomy o Preserve cartilage

Review article Logan J, Warwick D (2015) The treatment of wrist arthritis. Bone Joint J 97-B : 1303-1308

Your own cartilage and subchondral bone is better than metal and plastic

Is there preserved cartilage?

If there is preserved cartilage use it

PRC or 4CF • Equal clinical outcomes • 60% ROM • 80% grip strength • 80% survivorship 10 years • PRC • easier • safer • cheaper Saltzman BM et al. (2015 ) Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: A systematic review . J Hand Surg Eur Vol 2015;40:450-457.

SNAC and SLAC is the capitate-lunate involved? • No • PRC • 4CF • Yes • 4CF  Do not do  Replacement  Total fusion

 Dupuytren’s Disease  Flexor Tendon Repair  Wrist Arthritis  Distal Radius Fractures  Scapholunate

Temper your enthusiasm to fix everything  Surgery is dangerous  Anatomy does not correlate with outcome  In the older patient  Low functional demands  Anatomy might correlate somewhat with outcome  In younger patients  High functional demands

Risks of k wires 26-28% risk of complication!! 24 McFayden I, Field J, McCann P, Ward J, Nicol S, Curwen C. Should unstable extra-articular distal radial fractures be treated with fixed-angle volar locked plates or percutaneous Kirschner wires? A prospective randomised controlled trial. Injury , 2011; 42(2):162-166. 25 Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A Prospective randomized trial. J Bone Joint Surg Am , 2009; 91(8):1837-1846.

J Hand Surg (E) 2014 39: 745-56 complication rate 16%, 8% material

J Hand Surg (E) 2013;38:118-25

Anatomy may make a difference in younger people Gliatis, Plessas and Davis (2000) Outcome of distal radius fracture in young people . J Hand Surg 25B;6:535-543 Grewal and McDermid (2007) The Risk of Adverse Outcomes in Extra-Articular Distal Radius Fractures Is Increased With Malalignment in Patients of All Ages but Mitigated in Older Patients J Hand Surg 32(a) 962-970

Over 60 to 65 years No difference for surgery vs non-op Chen Y, Chen X, Li Z, Yan H, Zhou F, Gao W., Safety and Efficacy of Operative Versus Nonsurgical Management of Distal Radius Fractures in Elderly Patients: A Systematic Review and Meta-analysis. J Hand Surg Am 2016; 41:404-13. Lutz K, Yeoh KM, MacDermid JC, Symonette C, Grewal R. Complications associated with operative versus nonsurgical treatment of distal radius fractures in patients aged 65 years and older . J Hand Surg Am, 2014; 39:1280-6.

So, should we fix distal radius fractures?  Earlier restoration of function  Avoid POP  Early movement  Restoration of rotation  Dorsal angulation  Improved strength  Midcarpal malalignment  Ulno-carpal abutment  Positive ulnar variance But to avoid OA No evidence…….

How many of these…..

End up with these…?